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Management of Chronic Gingivitis with localized periodontitis by Nonsurgical

(Phase I) Periodontal Therapy- A Case Report

Article  in  Update Dental College Journal · April 2018

DOI: 10.3329/updcj.v7i2.36211

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Case Report UpDCJ | Vol. 7 No. 2 | October 2017

Management of Chronic Gingivitis with localized periodontitis

by Nonsurgical (Phase I) Periodontal Therapy- A Case Report.
Khan M H I1,, Eka S A2, Iqbal M A3

Received: 18.09.2017 Accepted: 11.10.2017

Abstract:
Periodontitis is a chronic inflammatory disease of the periodontal tissues (periodontium) which
surround and support the teeth, that results in attachment loss and alveolar bone destruction leads to
ultimate tooth loss. It is caused by the bacteria present in dental plaque, which is a tenacious
substance that forms on teeth and gingiva just after teeth are brushed. Periodontal treatment is aimed
at controlling the infection in order to stop the progression of the disease and to be able to maintain a
healthy periodontium. Mechanical debridement of supragingival and subgingival biofilms, together
with adequate oral hygiene measures is the standard periodontal therapy. This mechanical subgingi-
val biofilm debridement consists of an initial (nonsurgical /phase I) phase involving scaling and root
planing (SRP) and the elimination of plaque retentive factors, followed by a surgical phase (if needed)
including the elevation of a tissue flap and bone remodeling in further stages. The adjunct use of
antibiotics has proven to additionally improve the outcome of periodontal treatment. A clinical case of
a 40-years-old male patient with generalized severe chronic periodontitis with localized gingival swell-
ing was treated with nonsurgical (phase I) periodontal therapy that was confined to oral hygiene
instruction (OHI), SRP with an adjunct antimicrobial regimen.

Key words: Chronic periodontitis, nonsurgical /phase I therapy, scaling and root planing (SRP).

1. Dr. Md. Huzzatul Islam Khan, B.D.S., Lecturer & Dental Surgeon, Dept. of Periodontology & Oral Patholo-
gy, Update Dental College & Hospital, Dhaka.
2. Dr. Sultana Akter Eka, BDS, Update Dental College & Hospital, Dhaka.
3. Dr. Md. Ashif Iqbal, B.D.S., D.D.S., Associate Professor & Head of Dept. of Periodontology & Oral Patholo-
gy, Update Dental College & Hospital, Dhaka.

Correspondence : Dr. Md. Huzzatul Islam Khan, E-mail: hiksaimum@gmail.com

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Update Dental College Journal Vol. 7 No. 2 | October 2017

Introduction Case Description

It is scientifically established that dental plaque is the A 40-year-old male presented for a consultation in the
primary etiological factor in the pathogenesis of perio- outdoor patient department (OPD) of Update Dental
dontal diseases and many epidemiological studies College & Hospital, Dhaka, Bangladesh. He gave a
clearly state the relation between dental calculus and history of taking betel nuts and betel quids with chew-
periodontitis [1,2]. Calcified bacterial plaque is known ing tobacco. Throughout his life, he did never visit any
as dental calculus. The degree of mineralization in dentist for dental treatment. After intra-oral examina-
supragingival and subgingival calculus is different, tion, dental surgeon of OPD detected supra and
but both are masked by a layer of bacterial plaque [3, subgingival plaque, calculus, bleeding on probing,
4]
. Relationship of calculus with periodontal patho- periodontal pockets around maxillary and mandibular
gens and bacterial by-products makes it somewhat molars, premolars and on the anterior regions. A
difficult to investigate its etiological role alone in perio- localized gingival swelling was also found in the lower
dontitis. Yet, it is widely accepted that calculus is a right anterior region between lateral incisor and
local contributory factor [5]. Calculus, having a rough canine (Figure:1 & 2).
surface and porous structure, is an ideal substrate for
bacterial colonization and serve as a reservoir for
toxic bacterial components and antigen [6]. Porphyro-
monas gingivalis, Treponema denticola, and Aggre-
gatibacter actinomycetemcomitans have been identi-
fied within supra- and subgingival calculus [7–9]. Calci-
fying nanoparticles are found in dental plaque may
contribute to the formation of calculus and pathogenic
calcification of epithelial cells [10]. Localized periodon-
tal inflammation can persist, leading to the break-
down of supporting tissues, if left untreated. Because
of this, removal of subgingival plaque and calculus is
a must need procedure for successful periodontal
therapy. Supragingival calculus can be seen through
naked eye examination, but clinical detection of Figure: 1. Showing accumulation of plaque and
subgingival calculus relies on tactile exploration of calculus
tooth surfaces with an explorer or probe. Calculus on
interproximal surfaces may be detected by periodon-
tal probe and more accurately by intra-oral periapical
radiographs, although the accuracy of detection
depends on radiographic projections [11]. The superior
periapical radiographs can only detect 43.8% of the
proximal surfaces that is verified visually after extrac-
tion [12]. Advanced technologies, including dental
endoscopes [13], fiber-optic probes [14], autofluores-
cence [15], and lasers [16], are being used recently to
better detect subgingival calculus. Although it is
difficult to remove subgingival calculus completely by
scaling and root planing (SRP) [17, 18], periodontal heal- Figure: 2 Showing localized gingival swelling
ing is noticed even in the presence of microscopically between lower right lateral incisor and canine
visible calculus [19]. Initial /nonsurgical stage of perio-
dontal therapy usually results in significant clinical The Dental surgeon referred him to the Periodontolo-
improvement and change of subgingival microbial gy OPD. The patient was advised for intra-oral peria-
flora [20, 21]. This report documents the treatment of a pical radiographs from the radiology department. The
patient with generalized severe chronic periodontitis radiographs revealed the presence of 40% alveolar
with localized gingival swelling using nonsurgical bone loss lower right lateral incisor and canine
/phase I periodontal therapy. (Figure: 3). Patient’s oral hygiene was poor with
plaque index score 2 and clinical signs of inflamma-

34
Update Dental College Journal
tion around all teeth were severe. Gingival index
score was 3. Average sulcus depth was 3 mm.
Based on the radiographic and clinical findings a
nonsurgical treatment plan was developed to address
the patient’s plaque induced chronic generalized
severe gingivitis with localized moderate periodontitis
and gingival swelling. SRP with an ultrasonic scaler,
followed by adjunctive treatment with a five-day
course of systemic Metronidazole 400 mg three times
a day. The patient was instructed to use a medi- um-
tuft brush to remove plaque and also dental floss as
an interdental cleaning aid.
Periodontal re-assessment was performed one
month after treatment, with an improvement shown
with regard to the following parameters: marked
reduction of gingival inflammation with gingival index
score 1, complete resolution of localized gingival
swelling, reduction in plaque (plaque index score 0)
and bleeding on probing was absent (Figure: 4).
Figure: 3 Showing periapical radiograph localized
alveolar bone loss between lower right lateral incisor
and canine
Figure: 4. Showing healthy gingiva with better oral
hygiene and complete resolution of localized gingival
swelling after a month.
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Vol. 7 No. 2 | October 2017
Discussion
This case illustrates the periodontal treatment of a
patient with generalized severe chronic periodontitis
with localized gingival swelling using nonsurgical
phase I periodontal therapy. In the first step after
taking patient’s oral hygiene practice information,
carefully gave emphasis on brushing and interdental
cleaning. Plaque control instructions were delivered
to the patient. In the second step, supragingival and
subgingival plaque and calculus were removed by
SRP using ultrasonic scaler machine with universal
insert type. SRP is still now regarded as the corner-
stone of periodontal therapy. Its effectiveness in the
treatment of chronic periodontitis accompanied by
good oral hygiene has been repeatedly shown [22, 23].
Subgingival calculus and plaque can be substantially
removed by SRP [17,24,25], creating a favorable
microenvironment for periodontal tissue healing. In
this case, initial nonsurgical periodontal therapy
reduced pocket depths. In some randomized clinical
trials, it has been indicated that SRP of molars leads
to a 0.67 to 1.2 mm mean reduction of periodontal
pocket depth at sites initially 4 to 6 mm deep and 0.94
to 2 mm reduction at sites initially deeper than 6 mm
[23]
. Isidor and Karring [26] reported a 3.7 mm reduction
of periodontal pocket depth at sites with angular
defects 12 months after SRP. The improvement
presented in this case was consistent with these
clinical studies. Nonsurgical periodontal treatment
usually leads to the formation of a long junctional
epithelium [27], and partial bone fill in an infrabony
periodontal defect can also occasionally occur follow-
ing careful SRP. Hwang, et al. [28] reported an
increase in bone density in sites with more than 3 mm
vertical alveolar bone loss after SRP. Reduction of
radiographic defect depth was a positively associated
use of adjunctive antibiotics [29]. It is very difficult to
attain complete removal of plaque and calculus in
deep pockets, indicated in previous studies [17,18,30].
Residual calculus amount is significantly correlated
with pocket depth [17,31]. The favorable treatment
outcome observed in this patient could be attributable
to several factors. The patient maintained a satisfac-
tory level of oral hygiene throughout his treatment in
our department. Adjunctive administration of Metroni-
dazole may have also enhanced the outcome. The
clinical benefits obtained from adjunctive systemic
antimicrobials can justify their use in patients with
periodontal disease [32]. It is clear that detection of oral
disease at sites that are difficult to access can be
challenging. If the patient had visited a dental hospital
or clinic, it should have been possible to detect the
Update Dental College Journal
presence of calculus, inflammation, deep probing
depths, and bone loss at an earlier point in time.
Conflict of Interests
The authors have no conflict of interests to declare.
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